3210-3216 CIRSOID A

Vol.3.Issue.3., 2015
(Jul-Sept.)
Bulletin of Pharmaceutical and Medical Sciences (BOPAMS)
A Peer Reviewed International Journal http://www.bopams.com
3210Dr. Krishna Kumar. M
UTERINE CIRSOID ANEURYSM , MIMICKING OVARIAN CYST; DOPPLER ULTRASOUND
AND MDCT FEATURES.
Dr. Krishna Kumar. M
Associate professor & HOD, Department of Radiology, DM Wayanad Institute of Medical Sciences,
Naseera Nagar, Meppadi P.O, Wayanad, Kerala.
Email: drmkrishnakumar@gmail.com
Dr. Krishna Kumar. M
ABSTRACT
Uterine arterio-venous malformations (AVM) are rare but potentially life-
threatening lesions that should be suspected in women of reproductive
age with unexplained vaginal bleeding and in postmenopausal women in
whom anechoic structures are detected at ultrasonography (US). Uterine
AVM may be acquired or congenital. Acquired uterine AVMs are caused by
an iatrogenic event such as curettage, therapeutic abortion & pelvic
surgery or as a result of pathological conditions such as, cervical
carcinoma, endometrial carcinoma, gestational trophoblastic disease or
infection.
Congenital AVMs are the result of abnormal development of primitive
vessels that result in connections between pelvic arteries and veins in the
uterus without an interconnecting capillary bed.
Color duplex Doppler Ultrasound is valuable in the detection and
characterization of many uterine vascular lesions, including arterio-venous
malformations (AVMs). Arteriovenous fistulas demonstrate a mosaic
pattern representing turbulent flow. Spectral analysis of intralesional
arterial flow demonstrates high-velocity flow with a low resistive index,
and spectral analysis of intralesional venous flow shows high peak systolic
velocities consistent with an arterial flow pattern.
AVM of the uterus may be noted incidentally by Computed Tomography
(CT) of the pelvis. Magnetic Resonance Imaging (MRI) is frequently used to
confirm and further characterize the sonographic findings of uterine AVM.
Catheter angiography and embolization are very effective in defining the
vascular anatomy and treating uterine vascular abnormalities
respectively.
Key words; Cirsoid aneurysm, Color duplex Doppler Ultrasound ,
Embolization, MDCT, MRI, Uterine AVM .
©KY Publications
INTRODUCTION:
Uterine arterio-venous malformation [AVM] is a rare condition, with fewer than 100 cases reported in
the literature [1]. It is a potentially life-threatening condition, as patients may present with profuse bleeding.
ColourDuplex Doppler ultrasound [US] provides a non invasive method for initially diagnosing this rare
CASE STUDY

(Jul-Sept.)
condition and confirmation can be made using diagnostic angiography. Conservative management or
embolisation is a preferable method of treatment in order to avoid a hysterectomy in patients of child-bearing
age.
This case report highlights our experience with a patient having this rare gynaecological condition in
our medical center.
MATERIALS AND METHODS:
Case Report:
A 36 year old female presenting with menorrhagia and chronic back pain was investigated in our
medicalcentre . Clinical examination was unremarkable. Hemogram showed hypochromic microcytic anemia
with hemoglobin of 8 gm%. Pelvic greyscale ultrasonographic examination [Figure 1] showed a lobulated
anechoic cystic lesion,measuring about 6x4cm in the right adnexa mimicking ovarian cyst.However enlarged
right ovary with functional cyst was seen separate from the cystic lesion.
Color Doppler sonography [Figure 2] demonstrate a mosaic pattern within the cystic lesion
representing turbulent flow.
Pulsed Doppler spectral analysis [Figure 3] of intralesional arterial flow demonstrates high-velocity
flow with a low resistive index, and spectral analysis of intralesional venous flow shows high peak systolic
velocities consistent with an arterial flow pattern.
MDCT Axial, coronal and sagittal [Figure 4] showed a lobulated hypodense lesion in the lower uterine
segment filling with contrast in the arterial and venous phase.
3D Volume rendered CT [Figure 5] image clearly depicted the uterine lesion with right feeding uterine
arteries and draining veins. An AVM was diagnosed. The diagnosis was confirmed at surgery and successful
surgical intervention was done.
RESULTS AND DISCUSSION:
Uterine AVMs are rare in nonpregnant womenand were first described by Dubreil and Loubat in1926
[2]. Since then, several terms have beenused to refer to these lesions, including cavernoushemangioma, cirsoid
aneurysm, racemose aneurysm,arterio-venous aneurysm, pulsatile angioma,and arterio-venous fistula [2–6].
However, it is a potentially life-threatening disorder in which patients present with vaginal bleeding
that may be profuse and cause hemodynamic instability. Thus, it is an important differential to be considered
in women of reproductive age with unexplained vaginal bleeding and in post-menopausal women when
anechoic structures are identified by US [7].
AVM consists of proliferation of arterial and venous channels with fistula formation and a mixture of
capillary-like vessels.The size of these vessels varies considerably, which probably accounts for the variety of
descriptive terms found in the literature. Uterine AVMs are generally congenital [7].
Congenital AVMs have multiple vascular connections and tend to invade the surrounding structures
(eg,muscle, skin, viscera). They are believed to result from arrested vascular embryologic development.
In contrast, arterio-venous fistulas are usually acquired and typically represent a single artery joining a
single vein. They have been reported as a consequence of previous uterine trauma (eg, prior pelvic surgery,
curettage), use of intrauterine contraceptive devices, pathologic pregnancy-related events, and previous
treatment for gestationaltrophoblastic disease.
Bleeding is the major presenting symptom in AVMs. Because these malformations are less common
after menopause, postmenopausal bleeding is rarely seen.
Congestive heart failure secondary to a vascular steal syndrome is a less common clinical
manifestation. Clinical examination may be unremarkable. At vaginal examination,audible bruits and a
pulsatile mass may be detected. In patients with a history of unexplained vaginal bleeding, the possibility of a
uterine AVM must be considered[7].
Many imaging methods have been used to diagnosepelvic AVMs. Contrast material– enhanced
computed tomography, duplex Doppler US, angiography and, more recently, magnetic resonance imaginghave
proved useful in this setting.

(Jul-Sept.)
In uterine AVMs, gray-scale US shows a normal-appearing endometrium, whereas the myometrium
contains multiple hypoechoic or anechoic spaces [Fig 1]. At color Doppler US, these cystic spaces generate
color signals in a mosaic pattern representing turbulent flow [Fig 2] [6]. Spectral analysis of the arterialvessels
within the lesion shows high-velocity flow with a low resistive index [approximately0.51–0.65] [Fig 3]. Spectral
analysis of venous flow demonstrates a similar pattern [Fig 3].
(a) (b)
(c) (d)
Figure 1a-d. showed a lobulated anechoic cystic lesion measuring about 6x4cm in the right adnexa
mimicking ovarian cyst.
(a) (b)

(Jul-Sept.)
(c) (d)
Figure 2a-d. Color Doppler sonography demonstrate a mosaic pattern with intermixing of colours within the
cystic lesion representing turbulent flow.
(a) (b)
(c) (d)
Fig 3a-d.Pulsed Doppler spectral analysis of intralesional arterial flow demonstrates high-velocity flow with a
low resistive index, and spectral analysis of intralesional venous flow shows high peak systolic velocities
consistent with an arterial flow pattern.

(Jul-Sept.)
(a) (b)
(c) (d)
Fig 4a-f . MDCT Axial, coronal and sagittal showed a lobulated hypodense lesion in the lower uterine segment
filling with contrast in the arterial and venous phase.
Fig 5.3D Volume rendered CT image clearly depicted the uterine lesion with right feeding uterine
arteries and draining veins.

(Jul-Sept.)
In this case, it is possible that a acquired form of uterine AVM was present in the patient, given the
history of uterine trauma such as curettage in the past and caesarean section.
In our study, we found that AVMs of uterus can be diagnosed by colour duplex Doppler sonography.
Wiebe and Switzer [8] reported similar findings. Contrast enhanced MDCT with 3D volume rendered images
clearly depicted the uterine mass with right feeding uterine arteries and draining veins further confirming the
duplex Doppler US findings.
Digital subtraction angiography [DSA] remains the gold standard for the diagnosis of AVM. Findings
with DSA include bilateral hypertrophy of uterine arteries that feed a tortuous, hypertrophic arterial mass with
large accessory feeding vessels, and early drainage into enlarged hypertrophic veins [9]. However, DSA is rarely
performed for diagnosis alone due to its invasive nature and is usually reserved when a patient requires
surgical intervention or embolization.
Management of uterine AVM depends on the hemodynamic status, degree of bleeding, patient age,
and desire for future fertility. Acute treatment involves stabilizing the patient’s hemodynamic status, and
stopping blood loss.Large lesions [involving the subendometrial tissue] usually require surgical intervention
while others respond to conservative management.
Traditionally, a hysterectomy was the treatment of choice. However, the patient’s desire for future
pregnancy is an important consideration, as there are now options available to avoid a hysterectomy. In stable
patients who have the ability for close follow-up, expectant, and long-term medical management may be
appropriate [10].
Since the first description of a successful embolisation treatment for uterine AVM in 1986, it has been
commonly used in the emergency setting as well as less urgent circumstances. Various embolic materials have
been used, including polyvinyl alcohol, histoacryl [glue], stainless steel coils, detachable balloons, and
haemostaticgelatine. Some cases may require repeat embolisation [9].
In addition, because uterine AVM is commonly diagnosed in women of childbearing age, angiographic
embolisation has made hysterectomy no longer necessary. Pregnancy following conservative medical
management of AVM and even after successful embolisation, although rare has been reported in literature
[11-12].
However, hysterectomy remains the treatment of choice in post-menopausal patients or as an
emergency treatment in life-threatening situations [13].
This case report highlights the use of Duplex Doppler US and MDCT for diagnosing uterine AVM in a
patient of childbearing age who presented with Menorrhagia.
CONCLUSION
Uterine AVMs are more common than previously thought. Uterine AVMs should be considered as a
possibility in cases of refractory intrauterine bleeding. Colour duplex Doppler sonography, contrast enhanced
CT or MRI are important for proper assessment of these lesions. The size and site of the lesions probably have
a major role in deciding whether the patient needs medical or surgical intervention, however further studies
are required to substantiate this hypothesis.
In addition, because uterine AVM is commonly diagnosed in women of childbearing age, angiographic
embolisation has made hysterectomy no longer necessary.
REFERENCES:
[1]. Hickey M, Fraser I. Clinical Implications of Disturbances of Uterine Vascular Morphology and Function.
BaillieresClinObstetGynaecol. 2000; 14(6):937–951.
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[3]. Gantchev S. Vascular abnormalities of the uterus,concerning a case of diffuse cavernous angiomatosis
of the uterus. Gen DiagnPathol 1997; 143:71–74.
[4]. Sugiyama T. Diagnosis of uterine arteriovenous malformation by color and pulsed Doppler
ultrasonography. Ultrasound ObstetGynecol 1996; 8:359–360.

(Jul-Sept.)
[5]. Jain KA, Jeffrey RB, Sommer FG. Gynecologic vascular abnormalities: diagnosis with Doppler US.
Radiology 1991; 178:549–551.
[6]. Abu Musa A, Hata T, Hata K, Kitao M. Pelvic arteriovenous malformation diagnosed by colorflow
Doppler imaging. AJR Am J Roentgenol 1989; 152:1311–131.
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Uterine Vascular Abnormalities. Radiographics. 2002;22:47–53.
[8]. Wiebe ER, Switzer P. Arteriovenous malformation of uterus associated with medical abortion.Int J
ObstetGynaecol. 2000;71:155–8.
[9]. Grivell R, Reid K, Mellor A. Uterine Arteriovenous Malformations: A review of the Current Literature.
ObstetGynaecol Survey. 2005;60(11):761–767.
[10]. HilwatiHashim, OuzreiahNawawi.Uterine ArteriovenousMalformation . Malays J Med Sci. Mar-May
2013; 20(2): 76-80
[11]. Chow TWP, Nwosu EC, Gould DA, et al. Pregnancy following successful embolisation of a uterine
vascular malformation Br J Obstet Gynaecol. 1995; 102: 166–8.
[12]. Poppe W, Van Assche FA, Wilms G, et al. Pregnancy after transcatheter embolization of a uterine
arteriovenous malformation. Am J ObstetGynaecol. 1987; 156: 1179
[13]. Delotte J, Chevallier P, Benoit B, Castillon J, Bongain A. Pregnancy after Embolisation Therapy for
Uterine Arteriovenous Malformation. Fertility and Sterility. 2006; 85(1):228e1–6.

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